Every finding on record at Elysian Hospice, Inc.

Based on document review and interview, it was determined the Hospice failed to ensure bereavement services were provided as required. --- Findings include: 1. On 10/7/25  review of the policy titled, "Bereavement Services (policy: 4.26.1, Policies and Procedures Manual for Hospice © 2009 MED-PASS, Inc. (revised 2014) )" was completed. The policy requires, "...Procedure 2. An initial Bereavement Risk Assessment will be performed as part of the Comprehensive Assessment...Procedure 5. Unless Bereavement Services have been refused…A bereavement plan of care will be initiated, which may include…The plan of care will note the kind of bereavement services to be offered and frequency of service delivery…. Procedure 9. Bereavement assessment and clinical notes are documented in the patient’s permanent clinical record."  2. The following records were reviewed for Bereavement Services on 10/07/25 at approximately 12:00 PM. The following records lacked an initial Bereavement Risk Assessment:            a)     Pt. #1  Start of Care (SOC) 09/22/25 Date of Death     N/A b)    Pt. #2  Start of Care (SOC) 03/26/25 Date of Death     N/A c)     Pt. #3  Start of Care (SOC) 12/03/24 Date of Death     N/A d)    Pt. #5  Start of Care (SOC) 09/10/25 Date of Death 09/17/25   e)     Pt. #6  Start of Care (SOC) 04/15/25 Date of Death 06/09/25   3. The following records were reviewed for Bereavement Services on 10/07/25 at approximately 12:00 PM. The following records lacked documentation of refusal for bereavement services:      a)     Pt. #1  Start of Care (SOC) 09/22/25 Date of Death     N/A b)    Pt. #2  Start of Care (SOC) 03/26/25 Date of Death     N/A c)     Pt. #3  Start of Care (SOC) 12/03/24 Date of Death     N/A d)    Pt. #4  Start of Care (SOC) 07/18/25 Date of Death 07/21/25 e)     Pt. #5  Start of Care (SOC) 09/10/25 Date of Death 09/17/25   f)     Pt. #6  Start of Care (SOC) 04/15/25 Date of Death 06/09/25   4. During an interview with the Chief Executive Officer (CEO) (E#1) on 10/08/25 at approximately 10:30 am, E#1 verbally confirmed the lack of the initial Bereavement assessment being completed. E#1 also confirmed that Bereavement refusals are not being documented.

Based on document review and interview, it was determined the Hospice failed to develop, implement, and maintain an effective, ongoing, hospice-wide data-driven quality assessment and performance improvement program since November 1, 2021. Therefore, the Condition of Participation, 42 CFR 418.58, Quality Assessment and Performance Improvement was not met, as evidenced by: Findings include: --- 1. The Hospice failed to ensure the QAPI program measured improvement in patient outcomes and hospice services. L561. 2. The Hospice failed to ensure the QAPI program measured, tracked, and analyzed quality indicators. L562. 3. The Hospice failed to ensure the QAPI program used quality indicators to design its program. L563. 4. The Hospice failed to ensure the QAPI program collected data to monitor effectiveness and identify opportunities for improvement.  L564. 5. The Hospice failed to ensure the QAPI program included performance improvement activities which were based on high-risk areas. L566. 6. The Hospice failed to ensure the QAPI program included performance improvement activities which were based on the incidence, prevalence, and severity of problems. L567. 7. The Hospice failed to ensure the QAPI program included performance improvement activities which were based on patient outcomes safety and quality of care. L568. 8. The Hospice failed to ensure the QAPI program included performance improvement activities that tracked adverse events, analyzed the cause, and implemented preventative actions. L569. 9. The Hospice failed to ensure the QAPI program measured performance improvement actions to ensure success. L570. 10. The Hospice failed to ensure the QAPI program evaluated performance improvement projects. L571. 11. The Hospice failed to ensure the QAPI program performance improvement projects were based on the scope and complexity of its services. L572. 12. The Hospice failed to ensure the QAPI program documented performance improvement projects. L573. 13. The Governing Body failed to ensure the QAPI program was implemented, maintained, and evaluated annually. L574. 14. A review of the Hospice QAPI binder on 10/8/2025, annotated the last QAPI documentation on 11/1/2021 as, “Performance Improvement Project updates”. The binder lacked documentation of ongoing QAPI meetings/activities addressing points 1 through 13 above, as required. 15. A review of the Governing Body binder with meeting minutes was completed on 10/8/2025. The binder lacked documentation of review of the findings of the QAPI committee, as required by policy, from December 13, 2021 through September 19, 2025.   16. The Policy 10.1.1, titled Quality Assessment and Performance Improvement (QAPI) Plan, from Policies and Procedures Manual for Hospice ©2009 MED-PASS, Inc., (Revised 2015), states:               “Objectives·       To collect and analyze data to improve identified processes and outcomes of care…..·       To collect and analyze data to improve identified processes of patient care/services as well as outcomes of patient care, leadership and managerial processes, as indicated…… ·       To meet federal CMS requirements for QAPI. Responsibility/Accountability 1. The Governing Body is ultimately responsible for QAPI and implementation of the QAPI plan……4. The QAPI committee will meet on a regular basis and will report findings to the Administrator/Director, who, in turn, will report to the Governing Body. Results will also be communicated by the QAPI committee to staff, including contract staff.” 17. An interview with the CEO (Chief Executive Officer), E #1, was completed on 10/8/2025 at approximately 10:05 AM. During discussion regarding lack of QAPI documentation, E #1 agreed the last documentation relating to QAPI was 11/1/2021, stating “Yeah, that needs to be updated.”

Based on document review and interview, it was determined for 2 of 4 (Pt #4, Pt #5) patient records reviewed, the hospice failed to ensure the comprehensive assessment was completed by all members of the Interdisciplinary Team (IDT) within 5 days of the election of hospice benefits. This has the potential to affect all patients who receive care by the hospice with a current census of 1 patient. Findings include: --- 1.Pt #4 Start of Care (SOC): 12/16/21 Diagnosis: Dementia. The record was reviewed on 10/19/22 at approximately 9:00 AM. The record noted the Masters of Social Worker (MSW) Assessment was completed on 1/6/22, greater than the five day requirement. 2. Pt #5 SOC: 3/2/22 Diagnosis: Chronic Obstructive Pulmonary Disease (COPD). The record was reviewed on 10/19/22 at approximately 11:00 AM. The record noted the MSW had a Missed Visit note dated 3/9/22, greater than the five day requirement. 3. During an interview on 10/21/22 at approximately 9:45 AM, E#1 (Clinical Supervisor) reviewed Pt #4 and Pt #5's record and verbally agreed the hospice failed to ensure the comprehensive assessment was completed by the MSW within the 5 day requirement and should have been.

Based on a review of Hospice policy, Clinical records, and staff interview, it was determined the Hospice failed to ensure bereavement services were provided as required. This was found in 2 of 2 (Pts. #2 and 3) clinical records reviewed for bereavement. This has the potential to affect all patients who receive care by the hospice with a current census of 1 patient. --- Findings include: 1. The policy titled "Bereavement Services (revised 2014)" was reviewed on 10/19/22 at approximately 2:00 PM. The policy requires, "...Procedure 2. An initial Bereavement Risk Assessment will be performed as part of the Comprehensive Assessment..." 2. The following records were reviewed for Bereavement on 10/19/22 at approximately 1:00 PM. The records lacked an initial Bereavement Risk Assessment: a) Pt. #2 Start of Care (SOC) 10/25/21 Date of Death 12/20/21 b) Pt. #3 SOC 12/24/21 Date of Death 1/18/22 3. During an interview with the (E#1) Clinical Supervisor and the Director of Nursing (E#2) on 10/19/22 at approximately 2:00 PM, E#1 and E#2 verbally confirmed the lack of the initial Bereavement.

Based on document review and interview, it was determined the Interdisciplinary Group (IDG) failed to accurately supervise patient care, ensure Plan of Cares (POC's) were developed, and POC's specified the visit frequencies. This has the potential to effect all patients who receive care by the Hospice with a current census of 1 patient and an unduplicated 12 month census of 5 patients. Therefore, the Condition of Participation, 42 CFR 418.56, Interdisciplinary Group, Care Planning Coordination of Services was not met, as evidenced by: --- The Hospice failed to ensure the IDG the IDG accurately supervised patient care and services. See L539 The Hospice failed to ensure written POC's were developed. See L545 3. The Hospice failed to ensure the reason for missed visits were documented and notified the physician. See L-0555 A 4. The Hospice failed to ensure services were provided per the plan of care. See L-055 B

Based on document review and interview, it was determined in 1 of 5 (Pt #2) patient records reviewed, the Hospice failed to ensure the interdisciplinary group (IDG) supervised and evaluated the care and services provided by the Hospice staff. This has the potential to affect all patients who receive care by the hospice with a current census of 1 patient. --- 1. Pt #2 SOC 9/16/21. Diagnosis: Dementia. The clinical record was reviewed on 10/19/2022 at approximately 1:00 PM. The record lacked a Plan of Care for the 9/16/22 admission and subsequent readmissions to Hospice on 10/25/21 and 12/1/21. The record lacked IDG meetings. 2. A review of the IDG Meeting Book was completed on 10/20/22 at approximately 1:00 PM. There were no IDG meetings held from 2/2021 through 2/2022. 3. On 10/20/2022 at approximately 1:45 PM an interview was conducted with Director of Nursing (E #2). E #2 stated the Plan's of Care were not completed as having difficulty with the computer system. There were no IDG meetings held during 2/2021 through 2/2022 as (E#2) did not realize they were required.

Based on document review and interview, it was determined in 5 of 5 (Pt #1,Pt #2, Pt #3, Pt #4, and Pt #5) patient records reviewed, the Hospice failed to ensure the Plan of Care (POC) was Developed and Individualized to meet the patient's needs. This has the potential to affect all patient's serviced by the Hospice with a current census of 1 patient. --- B. Based on document review and interview, it was determined in 2 of 5 (Pt #3 and #5) patient records reviewed, the Hospice failed to ensure the Plan of Care (POC) was developed to meet the patient's needs. This has the potential to affect all patient's serviced by the Hospice with a current census of 1 patient. Findings include: Pt. #3 Diagnosis: Dementia. Start of Care (SOC): 12/24/21. The clinical record was reviewed on 10/19/22 at approximately 1:30 PM. The record lacked a Plan of Care was developed for the patient. Pt. #5 Diagnosis: Chronic Obstructive Pulmonary Disease. SOC 3/2/22. The clinical record was reviewed on 10/19/22 at approximately 11:00 AM. The record lacked a Plan of Care was developed for the patient. During an interview with the (E#1) Clinical Supervisor and the Director of Nursing (E#2) on 10/19/22 at approximately 2:00 PM, E#1 and E#2 verbally confirmed the lack of the Plan of Care for Pt's #3 and #5. E#2 verbalized the Hospice has changed computer systems, the old system wasn't capturing and transferring information to the Plan of Care. Pt #1 SOC: 6/29/21 Diagnosis: Dementia. The record was reviewed on 10/18/22 at approximately 12:45 PM. The Comprehensive Plan of Care for the certification period 8/23/22 through 10/21/22 lacked documentation of allergies, durable medical equipment, supplies needed and "SN (Skilled Nurse) Evaluation Performed. Need for Hospice Services Indicated: Physician Contact: Verbal Certification Received..." Pt #4 SOC: 12/16/21 Diagnosis: Dementia. The record was reviewed on 10/19/22 at approximately 9:00 AM. The Comprehensive Plan of Care for the certification period 5/22/22 through 7/28/22 lacked documentation of medications, allergies, durable medical equipment, supplies needed, visit frequencies, emergency preparedness and "SN Evaluation Performed. Need for Hospice Services Indicated: Physician Contact: Verbal Certification Received..." During an interview on 10/21/22 at approximately 9:45 AM, E#1 (Clinical Supervisor) reviewed Pt #1 and Pt #4's records and verbally agreed the Plan of Cares were not completed and should have been. Pt #2 SOC: 9/16/2021 Diagnosis: Dementia. The clinical record was reviewed on 10/19/22 at approximately 1:00 PM. The record lacked patient and family goals, lacked a problem list and interventions. The record also lacked services necessary for the palliation and management of the terminal illness. An interview was conducted with the Director of Nursing (E #2) on 10/20/22 at approximately 1:30PM. E #2 reviewed the record and agreed the POC was incomplete and lacked the required elements.

Based on document review and interview, it was determined for 4 of 5 (Pt #1, Pt #2, Pt #4, Pt #5) patient records reviewed, the hospice failed to ensure that information between all disciplines providing care and services was documented and reported to the physician per policy. This has the potential to affect all patients who receive care by the hospice with a current census of 1 patient. --- 1. The policy titled "Home Health Missed Visit Policy" (revised 7/9/21) was reviewed on 10/19/22. The policy noted "Policy: A missed visit is an alteration of the plan of care... the physician must be notified within 24 hours... Visits should only be missed for adequate reasons... must be documented... Procedure: Visits should only be missed for adequate reasons and not staff convenience... " 2. Pt #1 Start of Care (SOC): 6/29/21 Diagnosis: Dementia. The record was reviewed on 10/18/22 at approximately 12:45 PM. The following missed visits lacked documentation of an adequate reason for the missed visit or that the physician was notified: Licensed Practical Nurse (LPN), 8/26/22; LPN, 9/6/22; Skilled Nurse Visit (SNV); 8/15/22; and LPN visit, 8/2/22. The Chaplain/Counselor Assessment dated 7/1/21 noted "Continuing Care Needed? yes... Revisit Date: 07/08/2021". The record lacked documentation the Chaplain revisited with Pt #1 since 7/1/21. 3. Pt #2 SOC: 9/16/22 Diagnosis: Dementia. The record was reviewed on 10/19/22 at approximately 1:00 PM. The following missed visits lacked documentation of an adequate reason for the missed visit and that the IDG (Interdisciplinary Group) or physician was notified. The record contained the Plan of Care Order dated 9/16/2021 indicating the Home Health Aide was to conduct 2 home visit's a week, The Medical Social Worker was to complete 1 visit a month, the Chaplin was to conduct 1 visit a week and the Volunteer was to conduct 1 visit a week. There was no documentation any visits were performed for the certification period from 10/25/22 thru 12/20/22. 4. Pt #4 SOC: 12/16/21 Diagnosis: Dementia. The record was reviewed on 10/19/22 at approximately 9:00 AM. The following missed visit lacked documentation of an adequate reason for the missed visit or that the physician was notified: Skilled Nursing Visit (SNV), 4/12/22. 5. Pt #5 SOC: 3/2/22 Diagnosis: Chronic Obstructive Pulmonary Disease (COPD). The record was reviewed on 10/19/22 at approximately 11:00 AM. The following missed visits lacked documentation of an adequate reason for the missed visit or that the physician was notified. Aide visit. 3/7/22, 3/9/22, and 3/11/22; MSW, 3/9/22 6. During an interview on 10/21/22 at approximately 9:45 AM, E#1 (Clinical Supervisor) reviewed Pt #1, Pt #4 and Pt #5's records and verbally agreed the hospice failed to ensure alterations to the frequency of visits were documented and reported to the physician per policy and that services were provided per the plan of care and should have been. 7. An interview was conducted on 10/19/22 at approximately 1:30 PM with the Director of Nursing (E#2). E#2 confirmed the missed visits and the lack of notification to the physician or IDT.

Based on document review and interview, it was determined for 2 of 5 (Pt #1, Pt #4) patients records reviewed, the hospice failed to ensure patients were screened for communicable disease per policy. This has the potential to affect all patients who receive care by the hospice with a current census of 1 patient. Findings include: --- 1. The policy titled "CoronavirusVirus Disease COVID-19 (Outbreak, Epidemic, Pandemic)" (revised 12/28/21) was reviewed on 10/19/22. The policy noted "When making a home visit, HHAs (Home Health Agencies) should identify patients at risk for having COVID-19 infection before or immediately upon arrival to the home. They should ask the patients about the following 1. International travel... 2. Signs or symptoms... 3. In the last 14 days, has had contact with someone..." 2. Pt #1 Start of Care (SOC): 6/29/21 Diagnosis: Dementia. The record was reviewed on 10/18/22 at approximately 12:45 PM. Of the 44 visits conducted between 8/1/22 through 10/14/22, only 9 (20%) visits noted a COVID screen was conducted before or immediately upon arrival to the home. 3. Pt #4 SOC: 12/16/21 Diagnosis: Dementia. The record was reviewed on 10/19/22 at approximately 9:00 AM. Of the 15 visits conducted between 7/1/22 and 7/28/22, only 3 (20%) visits noted a COVID screen was conducted before or immediately upon arrival to the home. 4. During an interview on 10/21/22 at approximately 9:45 AM, E#1 (Clinical Supervisor) reviewed Pt #1 and Pt #4's records and verbally agreed the hospice failed to ensure patients were screened for communicable disease per policy.

Based on a review of Hospice policy, clinical records, and staff interview, it was determined the Hospice failed to ensure bereavement services were provided as required. This was found in 2 of 2 (Pts. #2 and 3) clinical records reviewed were bereavement. --- Findings include: 1. The policy titled "Bereavement Services" was reviewed on 10/19/22 at approximately 2:00 PM. The policy required..."Policy...For up to one year following the death of the patient...4. After a patient death has occurred, the case will be discussed at the next IDG meeting..." 2. The following records were reviewed for Bereavement on 10/19/22 at approximately 1:00 PM the records lacked Bereavement follow up for one year after death and discussion at IDG (interdisciplinary group) meeting: a) Pt. #2 Date of Death 12/20/21 (date of last Bereavement mailing 4/20/22) b) Pt. #3 Date of Death 1/18/22 (date of last Bereavement mailing 5/18/22) 3. During an interview on 10/19/22 at approximately 1:45 PM with E#3 (Bereavement Coordinator), E#3 verbally confirmed the lack of the Bereavement for Pt's #2 and #3 until one year after death and at IDG meetings.

Based on document review and interview, it was determined the hospice failed to ensure written agreements were completed with nursing facilities that provide hospice care and staff were qualified by completing an orientation and demonstrated skills/competence. This has the potential to affect all patients that receive care in a nursing facility with a current census of 1 patient. Therefore, the Condition of Participation, 42 CFR 418.100, Organization and Administration of Services, was not met, as evidenced by: --- 1.The hospice failed to ensure staff completed an orientation per policy. See L-0661 2. The hospice failed to ensure skills/competence were assessed and oriented to specific job duty. See L-0663

Based on document review and interview, it was determined for 8 of 11 (E #1, E #4, E #5, E #6, E#7, E #8, E #10, E #11) Hospice employees, the hospice failed to ensure staff completed an orientation per policy. This has the potential to affect all patients who receive care by the hospice with a current census of 1 patient. Findings include: --- 1. The policy titled "Employee Orientation" (revised 3/2013) was reviewed on 10/20/22. The policy noted "1. Orientation for each employee will minimally include:... Hospice philosophy. Record keeping and reporting... Patient's rights... Written policies and procedures... Concepts of death and dying and bereavement. Emotional Support, psychosocial and spiritual issues. Pain management. Disease and medical conditions common to hospice..." 2. The personnel records were reviewed on 10/20/22 at approximately 1:00 PM. The following records lacked documentation the employees completed an orientation per policy: E#1 (Registered Nurse (RN), Date of Hire (DOH) 1/30/17; E#4 (RN), DOH: 5/28/19; E#5 (CNA), DOH: 3/23/15; E#6 (Spiritual Counselor), DOH: 3/26/21; E#7 (Nurse Practitioner), DOH: 10/7/20; E#8 (RN), DOH: 3/8/19; E#10 (Master of Social Work), DOH: 1/26/21; E#11 (Licensed Practical Nurse (LPN), DOH: 3/2/22. 4. During an interview on 10/20/22 at approximately 2:00 PM, E#3 (Bereavement Coordinator) reviewed the personnel records and verbally agreed the records lacked documentation staff completed an orientation per policy and should have been completed. 5. During an interview on 10/18/22 at approximately 11:15 AM, E#4 stated "I didn't really do any formal training (Hospice). (E#2, Director of Nursing) helped me in the beginning."

Based on document review and interview, it was determined for 8 of 11 (E #1, E #4, E #5, E #6, E#7, E #8, E #10, E #11) Hospice employees, the hospice failed to ensure skills/competence were assessed and oriented to specific job duty. This has the potential to affect all patients who receive care by the hospice with a current census of 1 patient. Findings include: --- 1.The policy titled "Employee Orientation" (revised 3/2013) was reviewed on 10/20/22. The policy noted "1. Orientation for each employee will minimally include:... Hospice philosophy. Record keeping and reporting... Patient's rights... Written policies and procedures... Training specific to job requirements... OSHA (Occupational Safety and Hazard Administration) requirements, safety and infection control. Orientation to equipment.... Concepts of death and dying and bereavement. Emotional Support, psychosocial and spiritual issues. Pain management. Disease and medical conditions common to hospice..."2. The personnel records were reviewed on 10/20/22 at approximately 1:00 PM. The following records lacked documentation of skills/competence assessment and oriented to specific job duties: E#1 (Registered Nurse (RN), Date of Hire (DOH) 1/30/17; E#4 (RN), DOH: 5/28/19; E#5 (CNA), DOH: 3/23/15; E#6 (Spiritual Counselor), DOH: 3/26/21; E#7 (Nurse Practitioner), DOH: 10/7/20; E#8 (RN), DOH: 3/8/19; E#10 (Master of Social Work), DOH: 1/26/21; E#11 (Licensed Practical Nurse (LPN), DOH: 3/2/22. 3. During an interview on 10/20/22 at approximately 2:00 PM, E#3 (Bereavement Coordinator) reviewed the personnel records and verbally agreed the records lacked documentation staff's skills/competence was assessed nor oriented to specific job duties and should have been. 4. During an interview on 10/18/22 at approximately 11:15 AM, E#4 stated "I didn't really do any formal training (Hospice). (E#2, Director of Nursing) helped me in the beginning."

Based on document review and interview, it was determined for 2 of 5 (Pts #3 and #5) patients, the Hospice failed to ensure the Medical Director and the Attending Physician reviewed the clinical information and provided a written Certification of Terminal Illness. This has the potential to affect all patients who receive care by the hospice with a current census of 1 patient. --- 1. Pt #3 Start of Care (SOC) 12/24/21 Diagnosis: Dementia. The record was reviewed on 10/19/22 at approximately 11:45 AM. The record lacked a Certification for Hospice by the physician. 2. Pt #5 SOC: 3/2/22 Diagnosis: Chronic Obstructive Pulmonary Disease. The record was reviewed on 10/19/22 at approximately 11:00 AM. The record lacked a Certification for Hospice by the physician. 3. During an interview with the (E#1) Clinical Supervisor and the Director of Nursing (E#2) on 10/19/22 at approximately 2:00 PM, E#1 and E#2 verbally confirmed the lack of the Certification for Hospice.

Based on document review and interview, it was determined the hospice failed to ensure the clinical records were accurately completed and maintained for each hospice patient. This has the potential to effect all patients that receive care by the Hospice with a current census of 1 patient and an unduplicated 12 month census of 5 patients. Therefore, the Condition of Participation, 42 CFR 418.104, Clinical Records was not met, as evidenced by: --- 1. The hospice failed to ensure records were completed per policy. See L-0679 2. The Hospice failed to ensure a Statement of Revocation and a discharge summary was completed per policy. See L-0684

Based on document review and interview, it was determined for 2 of 5 (Pt #1, Pt #4) patient records reviewed, the hospice failed to ensure records were completed per policy. This has the potential to affect all patients who receive care by the hospice with a current census of 1 patient. Findings include: --- 1. The policy titled "Patient Record Content" (Revised 2015) was reviewed on 10/18/22. The policy noted "The record must contain correct clinical information... will use a standardized format for records... be legible, clear, complete and appropriately authenticated... Each patient record will contain the following... Name... date of birth (identifying information)... A current medication profile... allergies..." 2. The policy titled "Patient Record Entries: Authentication" (revised 2014) was reviewed on 10/18/22. The policy noted "All entries will be dated and authenticated... signing first name... last name and title." 3. Pt #1 Start of Care (SOC): 6/29/21 Diagnosis: Alzheimer's Disease Unspecified. The record was reviewed on 10/18/22 at approximately 12:45 PM. a) The following lacked the patients name and identifying information: Individual Patient Emergency Preparedness Plan, Controlled Substance Agreement, Risk Evaluation and Mitigation (REM): Strategies to Promote the Safe use of Opioids, Management and Disposal of controlled Drugs for Patients and Families and a Hospice Aide Care Plan. b) The following lacked authentication: 2 Verbal Orders dated 7/14/22 and a Hospice Aide Care Plan (undated). c) The Recertification for Hospice for the certification dates 2/24/22 through 4/24/22 was completed by the Medical Director and signed on 12/20/21. The date of 12/20/21 on the top of the form had been wrote over as completed on 02/21/22. d) The Alzheimer's Disease/Dementia/Senile Degeneration of Brain, not elsewhere classified had a patient name and medical record number whited out and Pt #1's name written over the top. e) 8 Physician Orders for Pt #4 dated 4/2022 were filed in Pt #1's record. 4. Pt #4 SOC: 12/16/21 Diagnosis: Dementia. The record was reviewed on 10/19/22 at approximately 9:00 AM. a) The following lacked the patients name and identifying information: Controlled Substance Agreement, Risk Evaluation and Mitigation (REM): Strategies to Promote the Safe Use of Opioids, Management and Disposal of Controlled Drugs for Patients and Families and Home Oxygen Safety. Checklist. b) The following Physician Orders were not authenticated in a timely manner: 7 medication orders dated 2/2022 and 3/2022 were authenticated by the physician on 6/14/22 and a medication order dated 7/6/22 was authenticated on 9/27/22. 5. During an interview on 10/20/22 at approximately 3:50 PM, E#1 (Clinical Supervisor) stated "Orders should be signed within 30 days." 6. During an interview on 10/21/22 at approximately 9:45 AM, E#1 reviewed Pt #1 and Pt #4's record and verbally agreed the hospice failed to ensure records were completed per policy and should have been.

Based on document review and interview, it was determined for 1 of 1 (Pt #2) patient record reviewed who had revoked services, the Hospice failed to ensure a Statement of Revocation and a discharge summary was completed at discharge. This has the potential to affect all patients who revoke Hospice services by the hospice with a current census of 1 patient. Findings include: --- 1. The policy titled ";Discharge Criteria" was reviewed on 10/20/22 at approximately 12:45 PM. The policy required, ";Patient will be discharged from services as follows: ";Patient revoked.... A Hospice patient is receiving treatment for a condition unrelated to the terminal illness or related conditions in a facility with which Hospice does not have a contract and Hospice is unable to provide Hospice services." 2. The policy titled ";Revoking the Election of Hospice Care Policy" was reviewed on 10/20/22 at approximately 1:00 PM. The policy required ";A signed statement that the patient or representative revokes the patients election for Medicare coverage of Hospice care for the remainder of the election. The date that the revocation is to be effective..." 3. Pt #2 Start of Care: 9/16/22 Diagnosis: Dementia. The record was reviewed on 10/19/22 at approximately 1:30 PM. The record indicated Pt #2 had chose to receive medical care related to a fall that required transport via ambulance for treatment of laceration on 10/24/22 and on 11/30/22, patient and family chose to be discharged from hospice care to transfer to another facility for evaluation and treatment related to a fall. The record lacked documentation of a Revocation form and documentation of a discharge summary for both events. 4. During an interview on 10/20/22 at approximately 12:30 PM, the Hospice Administrator (E#1) reviewed Pt #s 2's record and verbally agreed the record lacked a revocation form and discharge summary for both events.

Based on observation, document review and interview, it was determined the hospice failed to ensure a written agreement was completed with the SNF/NF and that specific information and staff training was conducted as required. Therefore, the Condition of Participation 42 CFR 418.112, Hospices that provide hospice care to residents of a SNF/NF or ICF/IID, was not met. This has the potential to affect all patients that reside in a SNF/NF, who are serviced by the Hospice. Findings include: --- 1.The hospice failed to ensure a Nursing Facility Agreements were completed with SNF/NF. See L-0764 2.The hospice failed to ensure the SNF/NF was provided with the required information per policy. See L-781 3. The hospice failed to ensure staff at the SNF/NF were oriented to the hospice philosophy and palliative care per policy. See L-0782

Based on a review of 1 of 1 SNF/NF (Skilled Nursing Facility/ Nursing Facility) facility contract and staff interview, it was determined in 1 of 1 SNF/NF contracts reviewed in which the patients received Hospice care at the SNF/NF, that the Hospice failed to ensure that the SNF/NF contract included signatures from authorized representatives as per policy. --- Findings include: 1. The policy titled "Care to Residents of a SNF (Skilled Nursing Facility)/NF (Nursing Facility) or ICF/MR" was reviewed on 10/21/22 at approximately 10:30 AM. The policy noted "...Procedure...3. Hospice and SNF/NF...will have a written agreement...The agreement will be signed by authorized representatives of Hospice and SNF/NF..." 2. The contract between the Hospice and the SNF/NF care facility was reviewed on 10/19/22 at approximately 12:30 PM. The contract lacked signatures of either facility. 3. During an interview on 10/20/22 at approximately 2:30 PM with the Clinical Supervisor (E#1) and the Director of Nursing (E#2), it was verbally confirmed there was no signature on the contract by either facility.

Based on observation and interview, it was determined for 1 of 1 (Pt #1) home visit conducted, the hospice failed to ensure the SNF/NF was provided with the required regulatory information. This has the potential to affect all patients who receive care by the hospice within a nursing facility with a current census of 1 patient. Findings include: --- 1. During a tour of the SNF/NF on 10/18/22 at approximately 11:15 AM, E#4 (Registered Nurse) was unable to find Pt #1's (Start of Care (SOC): 6/29/21 Diagnosis: Dementia.) admission folder which should included the most recent plan of care, election forms, Hospice election form and advanced directives, certification of terminal illness, name and contact information of hospice staff, instruction on how to access the hospice's 24-hour on-call system, Hospice medication information specific to each patient, and physician orders. 2. During an interview on 10/18/22 at approximately 11:45 AM, E#4 stated "I called (E#2, Director of Nursing) and the folder is at the office." 3. During an interview on 10/18/22 at approximately 1:00 PM, E#2 verbally agreed the required information was not provided to the SNF/NF for Pt #1 and should have been.

Based on observation, document review and interview, it was determined for 1 of 1 home visit conducted, the hospice failed to ensure staff at the SNF/NF were oriented to the hospice per policy. This has the potential to affect all patients who receive care by the hospice within a nursing facility with a current census of 1 patient. Findings include: --- 1. The policy titled "Employee Orientation" (revised 3/2013) was reviewed on 10/20/22. The policy noted "Each employee and contracted staff...1. Orientation for each employee will minimally include:... Hospice philosophy. Record keeping and reporting... Patient's rights... Written policies and procedures... Concepts of death and dying and bereavement. Emotional Support, psychosocial and spiritual issues. Pain management. Disease and medical conditions common to hospice..." 2. During a tour of the SNF/NF on 10/18/22 at approximately 11:15 AM, the "CNA (Certified Nurse Aide) Training" binder was reviewed. The binder lacked documentation about hospice philosophy. 3. During an interview on 10/18/22 at approximately 11:15 AM, E#4 stated "I don't think any of the staff here (SNF/NF) are new and received any training. They just know the process (hospice protocol)." 4. During an interview on 10/21/22 at approximately 10:20 AM, E#2 verbally agreed the SNF/NF lacked documentation that staff completed an orientation per policy and should have been completed.